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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESt i ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 a P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This application is made in compliaace with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1705 N. Broadway city Stockton Lot Size/Acreage Owner's Name _Geo e__Schuler, _Inc_ Address 1705 N. Broadway Phone 948-5500 Contractor _____Osterberg & StLwark ddress 2741 River Road, ModestQense No. 446670 Phone 537=5767 i TYPE OF WELL/PUMP: NEW WELL ❑ ,WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ r PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS + INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS See_ Work Plan - 11/25/9 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 1 Fl Domestic/Private O Gravel Pack ❑ Tracy Type of Casing PVC Specifications. Schedule 40 I.1 Public rI Other. fl Delta Depth of Grout Seal, - Ap42rpX 5O 1 T Type of Grout Neat Cement` I I Irrigation 70Approx. Depth l I Eastern Surface Semi installed by Repair Work Done L] Type of Pump H.P. State Work Done O Well Destruction ❑ Well Diameter 2 i Sealing Material i Depth [ {� Dspth Filler Material rk Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is y - available within 200 feet.) 77f Installation will serve: Residence__'._ Commercial_ Other Number of living units: Number of bedrooms t Character of soA to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line # LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following- I can' 1 in the dormanc*of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif nla' ,y The applicant t all all r �in c n Complete drawing on reverse side. Signed Title: Vice President M Da1e: _ 6/16/93 r1ti FOR DEPARTMENT USE ONLY 2(r d- f. ! Application Accepted by - Date ` Area_ r Pit or Grout Inspection by Date 'r Final Inspection by Date Z I Additional Comments: Applicant - Return all cop to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box-2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK r�CA411 RECEIVED BY r DATE 4PERMI7'NO. • EH13•J{tattv.tMs1 ��✓� V�r�V 4� ' Q I' {Gj 'l✓� 1� �� E EH 1{•is